Healthcare Provider Details

I. General information

NPI: 1861069379
Provider Name (Legal Business Name): ALAN DWAYNE STATUM OTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 06/04/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8720 S. 101ST AVE
TULSA OK
74133
US

IV. Provider business mailing address

412 E BEAVER ST
JENKS OK
74037-4513
US

V. Phone/Fax

Practice location:
  • Phone: 918-965-0101
  • Fax:
Mailing address:
  • Phone: 918-637-4790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: